By the time Clinton County coroner Steve Talbott arrived at the scene of an overdose in southern Kentucky, the bottles of prescription pain pills usually had vanished. Friends and relatives of the dead rarely had answers to Talbott's questions: What kind of pills did they take and where did they come from?
A toxicology report often answered the first question. It was the second one that typically eluded Talbott. As overdose deaths soared, Talbott repeatedly called the state police, hoping they could identify the source of opioids poisoning his community, nestled in the foothills along the Tennessee border.
Now, with the release and analysis of a federal database tracking every pain pill sold in the United States at the height of the opioid crisis, one Clinton County pharmacy has come into sharp focus: Shearer Drug, located less than two miles from the funeral home that Talbott runs in Albany, Kentucky. The family-run pharmacy purchased nearly 6.8 million pills that contained hydrocodone and oxycodone from 2006 through 2012 - enough to give 96 pills each year to every person in the county of roughly 10,000 residents.
During this period, Shearer Drug procured more opioid pills on a per capita basis per county than any other retail pharmacy in the United States, according to The Washington Post's analysis of the federal database maintained by the Drug Enforcement Administration. In 2012 alone, Shearer Drug bought over 1.1 million pain pills - a 55 percent increase from 2006.
Kent Shearer, a 67-year-old pharmacist who has owned Shearer Drug since the late 1990s, according to state records, declined to discuss the volume of opioids dispensed at the pharmacy or answer other questions about his business. Shearer operates his pharmacy out of a building he has shared with a doctor who pleaded guilty in federal court in March to illegally prescribing opioids. Shearer and the doctor are business partners who co-own the building through a limited liability company, according to state records and the doctor's lawyer.
"I just can't make any comments," said Shearer, whose name is emblazoned in gold on the pharmacy's window.
Shearer Drug is among thousands of small, independent pharmacies - from Smith County Drug Center in Carthage, Tennessee, to Zion Pharmacy in Kanab, Utah - that handled large volumes of hydrocodone and oxycodone from 2006 through 2012 and until now have largely avoided publicity for their roles in the epidemic.
The pharmacies and the opioids they purchased are revealed in the DEA's Automation of Reports and Consolidated Orders System, known as ARCOS, which tracks every pain pill distributed nationwide. The Post and HD Media, which publishes the Charleston Gazette-Mail in West Virginia, waged a year-long legal battle for access to the database, which the government and the drug industry had sought to keep secret. A judge recently ordered the release of seven years of database records, which expose the paths of more than 70 billion pain pills distributed to about 83,000 pharmacies.
The DEA has maintained this database for roughly two decades but did not regularly mine the records to identify pharmacies buying unusual quantities of opioid pills, according to current and former DEA officials. The agency relies on drug companies and pharmacies to monitor and report suspicious purchases. Letting the industry police itself helped fuel the epidemic that has devastated communities and claimed nearly 100,000 lives from 2006 through 2012, lawyers for the local governments who are suing the drug companies contend.
"There's plenty of blame to go around. I don't know that anyone has been perfect in doing everything possible to eliminate the epidemic," said Douglas Hoey, chief executive of the National Community Pharmacists Association, which represents about 15,000 independent pharmacies. "I do look to the DEA for leadership."
Hoey cautioned against judging pharmacies based only on the number of opioids they handled. There are legitimate reasons small pharmacies can have outsize volumes, including proximity to a surgical center.
"The numbers don't always tell the whole story," Hoey said.
To study the pharmacies, The Post examined the total number of pills that contained oxycodone and hydrocodone sold to each pharmacy over the seven years, and other metrics, such as year-over-year orders and overdose death rates in the counties where the pharmacies are located. The review excluded some small cities that are designated as counties, which inflates the per capita calculations.
The analysis reveals nearly half of the opioid pills were purchased by just 15% of the drugstores, which include Shearer Drug and the other seven pharmacies mentioned in this article.
Many of the high-volume pharmacies had annual double-digit growth in pain pills and bought far more opioids than competitors in the same counties. The analysis also considered proximity to urban centers.
In Paintsville, Kentucky, where a winding creek snakes through the town of roughly 4,000 people, Value-Med Pharmacy and Medicine Cabinet Pharmacy purchased almost 20 million pills that contained oxycodone and hydrocodone from 2006 through 2012.
These two pharmacies accounted for 79% of the total opioid pills distributed to five drugstores in surrounding Johnson County.
The number of pain pills obtained by Medicine Cabinet surged more than 30% in both 2008 and 2009. Meanwhile, the death rate in the county climbed to nearly nine times the national rate. Owners for Value-Med and Medicine Cabinet did not return messages seeking comment.
Some of the pharmacies reviewed by The Post have had trouble with regulators or law enforcement, but for others there is no public record of any scrutiny by authorities. A DEA spokesman said he could not provide a complete list of all enforcement actions by the agency against pharmacies nationwide for violations of the Controlled Substances Act.
An hour east of Nashville, in the small town of Carthage, Tennessee, orders of pills that contained oxycodone and hydrocodone skyrocketed about 74% from 2006 through 2012 at Smith County Drug Center, a stately brick pharmacy with white columns.
Smith County Drug Center bought 9.5 million opioid pills, or more than half the painkillers distributed to the county's five pharmacies in those seven years. Smith County has roughly 19,000 people.
In all, Smith County Drug Center acquired enough opioids to give each person in the county 72 pills every year from 2006 through 2012. In that time, a total of 21 people died of opioid overdoses in the county, nearly three times the national death rate.
Janet Trainham, who identified herself as an owner of the pharmacy, declined to discuss the store's opioid sales when reached by phone.
"I'm not going to comment on that," Trainham said and then hung up. Follow-up calls and messages were not returned.
On Aug. 25, 2016, the DEA sent the pharmacy a "Letter of Admonition" identifying certain deficiencies, according to Kevin McWilliams, a DEA spokesman in the agency's Louisville field office. These DEA letters are not public and the agency would not reveal specifics. But McWilliams said the letters are "issued for matters relating to errors in record-keeping or security deficiencies."
He said the concerns raised in the letters are not criminal and provide pharmacies with the ability to take corrective action. McWilliams said there are no subsequent regulatory actions on file for Smith County Drug Center.
Even with repeated scrutiny from regulators, some pharmacists and their drugstores have continued to stay in business.
In 2000, James Fred Carrico was fined $500 by the Kentucky Board of Pharmacy for failing to properly dispense Percocet, among other issues, when he served as a pharmacist at a Walgreens in Louisville, according to board records.
Five years later, Carrico opened Booneville Discount Drugs in Owsley County, Kentucky, where a statue of the pioneer Daniel Boone is perched above the store's burgundy sign. Carrico's drugstore went on to purchase about 2.9 million pain pills from 2006 through 2012 - or more than 70% of the total pain pills distributed to the county's three pharmacies, according to the database.
That is the equivalent of 86 pills for each person every year in this impoverished community along the South Fork of the Kentucky River. Like many parts of Appalachia once rich in natural resources, Owsley has been ravaged by the disintegration of the timber and coal industries.
State records show that Carrico has faced alcohol- or drug-related charges eight times since 2009, and five times, the charges resulted in convictions. The pharmacy board suspended his license in 2011 and cited his arrest for driving under the influence several months earlier.
In 2012, Carrico and another pharmacist at the store paid a total of $60,000 to settle civil allegations that they improperly dispensed drugs, according to the Lexington Herald Leader. A DEA audit had found the Booneville pharmacy failed to maintain inventory records on controlled substances 65 times over 18 months. A spokesman for the U.S. attorney said he could not provide records on the case. Former U.S. attorney Kerry Harvey in the Eastern District of Kentucky declined to comment.
Despite more than a decade of documented problems, the Kentucky Board of Pharmacy in 2013 voted to reinstate Carrico's license with restrictions, according to board minutes. Carrico, 66, could not be reached for comment, and has been hospitalized since a fall in June, said his son, Matthew Carrico.
His son told The Post his father never worked behind the counter of the pharmacy after 2012, when the younger Carrico said he took over the pharmacy.
Matthew Carrico, 36, said that his father was a recovering alcoholic and struggled again after the 2009 killings of his wife and mother-in-law, which remain unsolved.
"You can only do so much to help someone," said the younger Carrico, who serves on the board of directors for the Kentucky Pharmacists Association.
He said he fired his dad from the pharmacy in 2018. State records document a change in ownership a month after one of his father's arrests.
"I could not distance myself more," Matthew Carrico said.
Still, he defended the pharmacy's high volume of opioids during his father's tenure, saying that roughly 40% of his customers came from two nearby counties and that many of them were recovering from injuries sustained working in the coal industry and other manual labor jobs. He said opioid prescriptions at Booneville have decreased since 2014, when the federal government tightened rules for prescribing hydrocodone.
Carrico said he typically won't fill pain pill prescriptions for doctors who aren't in Owsley or the surrounding counties and that he is often berated for refusing to refill prescriptions before they are due. The pharmacy gives out free naloxone, which can treat opioid overdoses, a program that is advertised in the drugstore window.
"People might say the pharmacists don't care. I do care," Carrico said. "This epidemic is destroying this area. How would I have any business if I helped facilitate this problem? I don't want people to think I'm part of the problem because I'm not."
In New Mexico, Davis-Fleck United Pharmacy bought nearly 4.5 million opioid pills from 2006 through 2012, or the equivalent of 53 pills for every person in Sierra County, The Post's analysis shows.
That volume may have attracted the attention of the DEA several years ago, according to owner Ron Golubski, who said agents visited him at the store located in the town of Truth or Consequences. The pharmacist said he explained that he managed accounts for four hospice facilities and, for a long time, was the only drugstore in a county that draws many retirees and veterans.
"My numbers are greatly skewed. I did not doubt that," Golubski said.
Golubski said he attempts to combat the diversion of pain pills by ensuring prescriptions are legitimate, and reporting patients who have attempted to use doctored prescriptions and a physician suspected of running a pill mill.
"I'm just one little drugstore in the desert and we do our best to try and curb it," Golubski said. "Once it leaves here, it's out of my control."
Many of the top-dispensing pharmacies nationwide have changed hands since 2012, and several of the new owners said in interviews that opioid prescriptions had fallen in recent years. They attributed the decline to more stringent prescribing habits by doctors and increased scrutiny by their pharmacists. The opioid epidemic has also morphed: It started with prescription pills, which led to increased heroin use, and has now spawned the fentanyl crisis.
"There just weren't any brakes put on the supply and the volume of opiates that went through our pharmacies until the last four or five years," said Kurtney Stirland, the former owner of Zion Pharmacy in Kanab, Utah.
From 2006 through 2012, Stirland's pharmacy purchased nearly 2.5 million pills that contained hydrocodone and oxycodone, or about 80% of the pills distributed to the three retail pharmacies in the county.
In 2009, state records show that he was fined by the DEA and disciplined by the Utah Board of Pharmacy for various problems at his pharmacy, including failing to conduct an annual inventory and maintain required controlled substance forms.
Stirland said he was "negligent" with the record keeping but never dispensed opioids without prescriptions. He said he also blames the drug manufacturers and distributors for the opioid epidemic.
"We all got caught off guard as the years went by," said Stirland, who sold the business in 2016 and still works there part time. "I think there's a huge profit motive by the manufacturers and the wholesalers. I think they kind of hung the independent pharmacies out to dry."
Karsten Josie, a pharmacist who started two years ago at Zion Pharmacy under the new owner, said the pharmacy takes a very strict approach to pain pills. Josie, whose grandmother died of opioid-related problems several years ago, said he counsels every customer on addiction risks and symptoms of dependence, and informs them about the anti-overdose medication naloxone. At the same time, he encourages people to consider other pain therapies.
"Taking an opioid shouldn't be a norm. It should be an exception," Josie said. "I try not to alienate patients. . . . However, it's my job to scrutinize that. There has to be more education on alternative options and more realistic expectations of pain and how much you've got to bear. I give it my best shot."
The pharmacy's current owner, Scott Robinson, said wholesalers put a ceiling on opioid purchases and he has never hit it.
Some of the stores with the top pill counts have shuttered entirely, including Tug Valley Pharmacy in Williamson, West Virginia, which bought nearly 9 million opioid pills from 2007 through 2012.
In July, Tug Valley Pharmacy's owner, Samuel "Randy" Ballengee, was indicted as part of criminal charges filed against opioid distributor Miami-Luken and two of its former executives, accusing them of conspiring to pour millions of addictive pain pills into West Virginia, Kentucky and Ohio. Ballengee and his attorney did not return messages seeking comment.
Three former DEA officials who spoke with The Post said the agency lacked the resources to police pharmacies from 2006 through 2012. This was partly because drugstores were rarely the starting point for investigations, said Barbara Boockholdt, who was then the chief of the regulatory section of the DEA's Diversion Control Division.
"If you go into a pharmacy, you have to show that the prescriptions are not legitimate - we just didn't have time," Boockholdt said. "One of my favorite quotes from that period of my life was: Too many bad guys, too little time."
In Clinton County, Kentucky, it took many years, and far too many deaths, before law enforcement began paying attention to the crisis, according to Talbott, the county coroner. Since 2006, 41 people have died of prescription opioid overdoses in the county, records show.
The federal investigation began in 2015 after Talbott noticed multiple overdose deaths involving patients of a local physician, Michael Cummings, and the Kentucky Board of Medical Licensure expert found Cummings' treatment of several patients fell below minimum standards of care, court records show.
In 2017, Cummings was charged in federal court with the illegal distribution of controlled substances, which resulted in the deaths of three patients, according to court records. Between 2009 and 2014, Cummings wrote prescriptions for an average of over 249,000 oxycodone pills, 438,000 hydrocodone pills and 347,000 benzodiazepine pills per year.
Court records do not identify the name of the drugstore where those prescriptions were filled but note that "a pharmacy, located in a small town and county in southern Kentucky, was one of the largest dispensers of controlled substances in the entire state. [Cummings] was far and away the largest source of prescriptions for the pharmacy."
Cummings had his medical practice in the same building as Shearer Drug in Albany. The 6.8 million opioid pills bought by Shearer Drug from 2006 through 2012 accounted for 66 percent of the total ordered by the county's five pharmacies, according to The Post's analysis.
Shearer, who opened a second pharmacy a few miles away in 2016, told The Post he had not faced past enforcement action and declined to discuss his business relationship with Cummings.
Cummings pleaded guilty in federal court in March to 13 counts of illegally prescribing controlled substances outside the course of professional medical practice and without a legitimate purpose. He was sentenced on July 24 to 30 months in prison and ordered to pay a $400,000 fine.
"Michael Cummings was a guy who lived his life dedicated to his family, his church and his patients. And he did a lot of good," said Kevin Tierney, an attorney for Cummings.
Talbott, who said he grew up with Shearer and attended the same school, hasn't talked to the pharmacist in a few months.
When Talbott, 67, learned from The Post's analysis that Shearer Drug had purchased nearly 6.8 million pills that contained hydrocodone and oxycodone over seven years, the county coroner responded: "It's a lot of pain medication for this little town."
Talbott said the overdose deaths have waned since Cummings was indicted in 2017, but the epidemic is far from over.
"There were just too many people dying from these drugs in such a small place," Talbott said. "I hate these drugs. They are awful."
This article was written by Jenn Abelson, Beth Reinhard, Andrew Ba Tran and Aaron Davis, a reporter for The Washington Post.